Medicine 2017 Release Flashcards
54M - PCx: intermittent palpitations
No history of cardiac disease or HTN
ECG shows AF
Manage?
Diagnosis = Atrial Fibrillation (AF)
Manage:
1) Symptom relief
2) Anti-coagulation
1) Symptom relief: Rate vs Rhythm control
a. Rate control
- give beta blocker e.g. Metoprolol, Bisoprolol; or non-dihydropyridine CCB e.g. Diltiazem, Verapamil.
- for CCF patients: give Digoxin.
b. Rhythm control
- depends on whether patient is haemodynamically stable
+ if haemodynamically unstable (due to rapid ventricular rate e.g. VT, lack of cardiac output), consider electrical cardioversion.
+ if haemodynamically stable, consider either electrical cardioversion or medications.
meds include Flecainide, or Propafenone.
2) Anti-coagulation: patient’s stroke risk needs to be balanced against their bleeding risk.
- stroke risk is calculated using CHADS-VASc score.
0 = no meds
1 = Aspirin
2 or above = Anticoagulation e.g. Warfarin
- bleeding risk is calculated using HASBLED score.
67M - PCx: chest pain on exertion for several weeks
is to have coronary angiogram
Explain risks and benefits of the procedure, and how it will be performed.
1) Environment: quiet, interpreter, check competence, use lay language and visual aids.
2) Assessment: includes history, exam and investigations.
- assess patient’s risk level of IHD:
+ high-risk features: CCF (elevated JVP, pulmonary crackles/effusion, lower limb oedema), PVD (arterial bruits, diminished arterial pulses).
- ECG
3) Indications and Contraindications for C.A.:
Indications: - angina that significantly interferes with patient's life despite maximal medical therapy - high-risk IHD features: \+ ECG \+ echo abnormalities
Contraindications: relative
- decompensated CCF
- very poor kidney function
- CVA (stroke)
- anaphylaxis to contrast agent
4) Procedure: it’s a day procedure.
- Pre-procedure:
+ NBM since mid-night (12am)
+ Basic tests: FBC, EUC, LFTs, coats, ECG, CXR
+ if diabetic, cease Metformin on the day, and for 48h after. may need IV Insulin + Dextrose as a replacement
+ if CKD, consult renal physician.
+ ?if allergic to contrast agent, give Prednisolone the day before - During procedure:
+ t = about 30 minutes
+ patient is attached to continuous ECG monitoring and sedated with Diazepam 10mg PO
+ cardiologist places local anaesthetic into the arm/groin, depending on where the catheter (long thin tube used to convey the contrast agent) is inserted
+ catheter after inserted is advanced under the guidance of X-ray vision
+ dye is injected into the catheter, which would then flow into the cardiac chambers and the coronary arteries. blockages of coronary arteries will be visualised
+ then cardiologist would decide whether to do angioplasty or stenting. - Post-procedure:
+ catheter is removed and pressure applied to the area
+ patient moved to the ward to stay for 6 hours, and then be discharged
+ follow-up appointment with cardiologist to discuss results
+ given meds: statin, ACEi, beta blocker and aspirin.
Risks and Benefits:
- Benefit: treat the coronary arteries blockages
- Risks:
+ Systemic risks:
- Death: < 0.1%
- Heart: < 0.1% - includes acute MI, systemic embolisation of atheromatous debris, ventricular tachyarrythmias, perforation of great vessels, cardiac tamponade
- CVA (stroke): rare
- Kidney related: acute kidney injury
- Anaphylaxis: to drug agents
+ Local risks:
- Pain
- Haematoma, aneurysm formation, vessel dissection
- Thrombosis formation
- Infection: extremely rare
Alternatives: CT coronary angiogram
Patient concerns: patient can raise concerns, ask questions
67M with cardiac failure - PCx: increasing dyspnoea, ankle oedema
Current meds: Frusemide, Enalapril
Manage?
Diagnosis:
PDx = Acute decompensated heart failure (ADHF)
DDx = PE, pneumonia, asthma, non-cariogenic pulmonary oedema
1) Resusc: while patient is UPRIGHT (lying down makes it worse), ABCDE with particular focus on ABC
- alert senior colleague
- Airway: if non-invasive ventilation fails, need rapid intubation (hence someone senior is important)
- Breathing:
+ CPAP
+ if CPAP fails, do mechanical ventilation
- Circulation:
+ ECG
+ IV cannula
+ Nitrates (sublingual 0.8mg) if SBP > 90 mmHg: to decrease fluid overload and improve gas exchange.
2) History, exam, investigations History: - Symptoms - Rule out red flags (Ddx): \+ PE: haemoptysis, collapse \+ pneumonia: fever, cough - Figure out causes of ADHF: \+ MI: chest pain +/- radiation \+ arrhythmias: syncope - CVS risk factors
Exam: vitals, cardio-respiratory exam
- ADHF features: lung crackles, heart signs (elevated JVP, heart murmurs), lower limb oedema.
Investigations: - Bedside: ECG (ST elevation) - Labs: trops - Imaging: \+ CXR signs of ADHF: cardiomegaly, batwing appearance due to lung hilar congestion, interstitial infiltration (pulmonary oedema), pleural effusion. \+ Echo
Management:
1) Emergency measures:
- monitor airway, breathing, circulation
- give O2: non-invasive ventilation (NIV), then intubate if required
- Nitrates if SBP > 90mmHg
- LMNOP: \+ Lasix: Frusemide \+ Morphine \+ Nitrates: GTN \+ Oxygen \+ Positioning: UPRIGHT
- if patient in cardiogenic SHOCK: \+ admit to ICU \+ assist LV function with: * IV Adrenaline or Dobutamine * if above fails, do intra-aortic balloon pump (to support perfusion), or LVAD (left ventricular assist device). * treat underlying arrhythmias
2) Treat underlying cause:
- acute MI: Aspirin and revascularisation (PCI)
- valvular pathologies: percutaneous valvulotomy
57F with intermittent AF on Holter monitor - PCx: palpitations
Assess and manage her risk of stroke complicating AF.
Anti-coagulation: patient’s stroke risk needs to be balanced against their bleeding risk.
- stroke risk is calculated using CHADS-VASc score.
0 = no meds
1 = Aspirin
2 or above = Anticoagulation e.g. Warfarin
- bleeding risk is calculated using HASBLED score.
26F - PCx: tiredness, palpitations & heat intolerance
O/E: diffusely enlarged thyroid
Assess?
PDx: Graves' disease She had features of hyperthyroidism. DDx include: - Graves' - toxic multi-nodular goitre - toxic adenoma - painful subacute thyroiditis - drug-induced hyperthyroidism e.g. amiodarone - post-partum thyroiditis
DIFFUSE goitre makes Graves’ disease more likely.
1) Resuscitate: if thyroid storm/thyrotoxicosis
- aggressive IV fluids
- high-dose anti-thyroid meds
- iodide supplementation: to suppress T3/T4
- Dexamethasone
- continuous ECG monitoring
- manage high-output cardiac failure with beta-blocker
2) History and Exam
History:
- Symptoms
- Risk factors: female aged 20-40, autoimmune diseases e.g. diabetes, Celiac
Exam: thyroid exam
3) Investigations:
- Bedside: ECG
- Lab:
+ TFTs: TSH (down), T3 & T4 (up)
+ TRAb (stimulatory TSH receptor antibodies) and TPO (thyroid peroxidase antibodies): both up in Graves
- Imaging:
+ thyroid isotope scan
+ radioactive iodine uptake
4) Further Management:
- Meds:
+ Symptom relief: - Beta blocker (Propranolol, Atenolol): relieve palpitations, tremor and sweating
- Steroids (Prednisolone): for ophthalmic (eye) symptoms
+ Anti-thyroid meds:
- Carbimazole
- Propylthiouracil (PTU)
- monitor T3/T4 every month
- Surgical resection: if
+ large goitre causing obstructive symptoms
+ patient with co-existing thyroid nodules
+ women desiring pregnancy within next few months
60F - PCx: fasting BSL of 14.7 mmol/L
attends diabetes clinic for the first time
Assess and manage.
PDx: Diabetes mellitus, most probably type 2
Diagnostic criteria for T2DM: on 2 seperate occasions
- fasting BSL >= 7
- 2 hour post-meal OGTT >= 11
- HbA1c >= 6.5%
OR with symptoms AND positive reading on 1 occasion
1) History:
- Symptoms
- Risk factors:
+ modifiable
+ non-modifiable
2) Examination:
- Cardiovascular
- Peripheral vascular
- Eyes
- Sensation: for peripheral neuropathy
3) Investigations
- To confirm diabetes:
+ another fasting BSL or HbA1c
+ test for T1DM with antibody testing
- Test for potential complications of DM:
+ macro-vascular: ECG, ABI
+ micro-vascular: retinal exam, U/A for albumin-Cr ratio, EUC
4) Treatment:
- Non-pharm:
+ healthy diet
+ exercise
+ stop smoking - Pharm:
+ First-line: Metformin (NOT cause weight gain)
+ Second-line: ADD Sulphonylurea, Others include Thiazolidinedione, DPP4 inhibitor, Acarbose, SGLT2 inhibitor, GLP1 agonist and Insulin. - Refer to allied health professionals: endocrinologist, diabetes educator, podiatrist, dietician.
68F - PCx: abdominal distension
O/E: 10cm shifting dullness, no organomegaly
Assess.
DDx for ascites:
- Liver cirrhosis: 80%
- Malignancy: 10%
- Heart failure: 3%
- Nephrotic syndrome
- Tuberculosis: 2%
- Pancreatitis: 1%
Causes of cirrhosis:
- infection/hepatitis
- drug related: alcohol, methotrexate
- autoimmune
- hereditary: Wilson
- endocrine: NASH
1) Rule out life-threatening DDx that necessitate emergent management e.g. SBP, encephalopathy (due to liver failure). Hence proceed with history et al.
2) History:
- Symptoms:
+ Ascites: onset, duration
+ Cirrhosis symptoms: confusion, jaundice, easy bruising, leg swelling
- Risk factors:
+ Hep B/C infection: needle sharing, tattoos, multiple sexual partners
+ Drugs: comprehensive alcohol and med history
+ Auto-immune hepatitis
+ Hereditary: Wilson’s
3) Examination:
full gastro
4) Investigations:
- Lab:
+ Bloods: FBC, platelets, EUC, LFTs, alpha fetaprotein (AFP) for HCC
+ Serology
+ Ascitic fluid test
- Imaging:
+ Fibroscan
+ Liver biopsy
+ CT abdomen/pelvis
+ whole body PET-CT scan
35M with chronic hep C - PCx: to have a liver biopsy
Assess risks, benefits. How to assess post-procedure?
Liver biopsy consent Framework: - Indications - Risks and Benefits - Assessment: history, examination, investigations - Procedure - Alternatives - Assessment post-procedure
1) Indications:
- Primary indication = grade and stage his chronic hep C
- Other indication: if there is uncertainty re the aetiology of his chronic liver disease
2) Risks and Benefits:
- Benefits:
+ determine the severity of the disease, hence prognosis, hence how urgent treatment needs to be
- Risks:
+ common = pain in RUQ/right shoulder
+ major risks:
*death: 1 in 1000
*bleeding
*bile peritonitis
*perforation
*damage to surrounding structures
3) Assessment: mainly re bleeding risk
History
- enquire about HCV diagnosis
- any liver biopsy before? any complications?
- medications (that may increase bleeding risk): anti-platelets, NSAIDs, anti-coagulants
Investigations
- FBC: low platelets in chronic liver disease
- coags: INR, aPTT
- EUC: kidney function
4) Procedure:
- first localise the site of biopsy with patient supine: percuss until the point of maximal liver dullness
- confirm using liver US
- inject local anaesthetic
- make a small incision with a scalpel
- insert a biopsy needle to collect sample
- sedate if patient is anxious
5) Alternatives:
- trans-jugular approach under IR (interventional radiology)
- non-invasive: e.g. fibroscan, US, CT scan
HCC: - NO need for biopsy due to risk of seeding and bleeding - Ix: US + alpha fetoprotein (AFP) - very aggressive usually - Curative approaches: \+ liver transplant \+ radio-frequency ablation \+ surgical resection - Palliative approaches: chemotherapy
58M - PCx: 2-month history of RUQ discomfort and weight loss
LFTs normal
CT scan of abdomen shows a solitary mass in liver
Assess.
Liver cancer assessment
35F - PCx: asks for drug to lose weight previously well BMI 32, clinically well FHx: T2DM Advise.
Introduction
60y past myocardial infarction with BMI 30 o Falls into category of obese
o After a myocardial infarction is a good time for motivating lifestyle change Approach:
o Prepare environment for conversation
o Motivational interviewing over multiple consultations (if possible) with regular follow up o Practical advice
Prepare environment
Calm, comfortable environment
Explanations made in simple terms without jargon
Open conversation rather than dictation
Motivational interviewing
Confirm she is overweight: o Weight, height, BMI
o Waist, hip circumference, W:H ratio
o Secondary cause: medications – eg. Steroids, hypothyroidism
5As approach
Ask
o If she has thought about losing weight
Assess
o Whether she wants to lose weight
Patient-initiated reasons for and against
Advise
o In simple terms to lose weight incorporating patient-initiated reasons o Incorporate recent heart attack and increased risk
Assist
o Education about weight gain and loss
Balance between intake and output
Weight loss is achieved when output is > intake Difficult and slow, no magic bullet
o Set goals o Diet
Assess current diet
Advise:
3 meals and 2 snacks/day
Correct portions
Everything in moderation Avoid:
o Soft-drink, take away, junk food Consider dietician referral
o Exercise
Simple activity, incidental activity 30 minutes/day (at least 5x/week) Work into routine
o Meds: phentermine, orlistat
o Surgical (BMI>40): sleeve gastrectomy (needs BMI>50 or >35 with comorbiditiy), adjustable gastric banding,
roux en y gastric bypass Arrange
o Follow up, MD team including dietician, psychologist if appropriate o Regular review with GP
Encourage success, reassure in failure
76F - PCx: has fallen over x2 past 3 days
is in nursing home
Assess.
Aetiologies of falls: SENDHUGS
- Sepsis
- Electrolyte disturbances: hypoNa+
- Neurological
- Drugs
- Hypoxia
- Uremia
- Glycemic
- Shock
History: - Re the fall: location, activity at the time, injuries sustained - Risk factors - Medications: \+ anti-hypertensives \+ anti-coagulants
Examination:
- Neurological
- Cardio-respiratory
- Musculoskeletal
Investigations:
- Bedside
- Lab
- Imaging
Management:
- treat underlying cause
- MDT approach
60M - PCx: DVT on right leg (2 months after stopping Warfarin for a similar episode on left leg)
Manage.
Main aim = anti-coagulate him (to prevent VTE which can be fatal e.g. PE). Likely life-long this is his second DVT.
Other indications for indefinite anticoagulation are:
- active cancer
- multiple thrombophilias
- anti-phospholipid syndrome
History:
- ask why Warfarin was stopped? e.g. SEs
- systems review:
+ features a/w recurrent DVTs: malignancy, nephrotic syndrome, FHx of thrombophilia, protein C/S and anti-thrombin deficiency, CT disorders, anti-phospholipid syndrome
Examination:
- leg swelling, erythema, pain
- systemic examination: look for evidence of malignancy
Investigations: - Lab: \+ FBC: platelets \+ coags \+ EUC \+ thrombophilia screen: anti-phospholipid antibodies e.g. lupus anticoagulant, beta-2 glycoprotein, anti-cardiolipin antibodies
Management: - Non-pharm: \+ encourage mobilisation \+ graduated compression stockings: from knee to ankle \+ encourage adequate hydration
- Pharm:
LMW Heparin: Enoxaparin SC
OR
UFH SC
PLUS Warfarin PO
+ initiate both at the same time
+ if patient has kidney failure, use UFH instead
+ testing for Warfarin: INR daily until 2-3 for 2 consecutive days
* if use UFH, monitor aPTT
30M - PCx: recently diagnosed with HIV
following a routine test as part of sexual health assessment
asymptomatic
Assess and manage.
Not sure…
Anti-retrovirals?
63F - PCx: aching shoulders & hips for past month
not noticed any weakness but pain is affecting her activities
feels tired
appetite is good. weight is stable
PHx: hypercholesterolemia - 3 months ago, treated with Simvastatin
Assess and manage.
Diagnosis: Statin-induced myopathy (SIM)
DDx: fibromyalgia, myositis (dermatomyositis, polymyositis), and arthritis
History:
- Symptoms of statin-induced myopathy:
+ classic presentation: proximal symmetrical muscle weakness and/or soreness with functional deficits (e.g. unable to raise arms above head, unable to rise from a seated position, unable to climb stairs)
+ onset of symptoms relative to statin treatment: tends to be within weeks-months of initiation of statin
- Rule out rhabdomyolysis: muscle pain, nausea, vomiting, abdo pain, fever, tachycardia, dark urine, altered consciousness
- Risk factors for SIM:
+ liver or kidney failure
+ hypothyroidism
+ those take drugs that inhibit CYP450 3A4 system
Examination:
- Vitals
- U/A: rhabdo shows blood
- MSK exam: of affected joints et al
- Neuro exam: for power
Investigations: SIM is a clinical diagnosis, confirmed with patient improvement after cessation of statins
Additional tests may be helpful: - Lab: \+ serum CK \+ urinary myoglobin: check for myonecrosis and rhabdomyolysis \+ EUC: for AKI \+ vit D, TFTs: elevated TSH, low T3/T4.
- Imaging: X-ray of affected joints - screen for OA, RA
Management: mainly pharmacological
- Cease statins
- Consider switching to another type of statin (e.g. fluvastatin/pravastatin), or other classes of cholesterol-lowering drug (fibrates, bile acid binding resins)
- Treat vit D deficiency, hypothyroidism if present (as they worsen myopathy).
36F - PCx: almost daily headaches for past 3 months
otherwise asymptomatic
Assess and manage.
Diagnosis = Tension headache
a type of chronic headache
DDx:
- other headache syndromes: migraine, cluster headache
- space occupying lesion
- trauma
- infection: encephalitis (rare)
- rheumatological: giant cell arteritis
History:
- Symptoms:
+ pain history: SOCRATES et al e.g. age of onset, triggers (psychological stress, financial/relationship issues, etc.) - Rule out red flags:
+ space-occupying lesion: signs of increased ICP e.g.
- early morning headache
- a/w changes in posture/vomiting
- personality changes
- changes in cognition/consciousness
- seizures
+ stroke/CVA:
- neurological deficits
- severe headache
+ trauma: head injury
+ infection:
- meningism: neck stiffness, photophobia and headache
- altered consciousness
+ giant cell arteritis:
- visual disturbance
- jaw claudication
- Medications and allergies:
+ meds can cause headache as SE: CCB, nitrates, dipyridamole
+ headache as after acute withdrawal of a drug: alcohol (hangover headache), analgesics withdrawal (aka medication overuse, rebound headache)
+ COCP
Examination:
- Vitals
- Cranial nerve examination: look for CN palsies, raised ICP (via fundoscopy) -> mass, infection
- GCA: palpate temporal arteries, assess for jaw claudication
Investigations:
Chronic headache is a clinical diagnosis. Investigations are only performed if suspect a secondary cause.
If patient presents with classic symptoms of a type of chronic headache e.g. tension, migraine and their neuro exam is normal, may not need to do ix.
If suspect secondary cause, do MRI brain: look for stroke, vascular lesion, mass, infection.
Management: depends on the cause of headache
- Non-pharm: similar for all types of headache
+ Avoid headache triggers: stress, certain foods, poor sleep
+ Rest in a quiet, dark room
+ Avoid activities e.g. reading, watching TV - esp. for migraines
+ Encourage headache diaries: document episodes of headaches, associated symptoms, triggers
+ CBT: for coping skills, relaxation techniques
+ Modification of SNAP risk factors
+ Discourage over-reliance on caffeine - Pharm:
1) Migraine:
1st line = Paracetamol 1g PO 4hrly
OR Aspirin OR another NSAID
Add Metoclopramide 10-20mg PO (anti-emetic) if need be
2nd line = Triptans (agonist serotonin receptors) PO/nasal
3rd line = Dihydroergotamine SC/IM
used in refractory migraine
works similarly to triptans
2) Tension headache:
1st line = Paracetamol
if headache is chronic and unremitting, give preventer e.g. TCA amitriptyline 10mg PO.
3) Cluster headache:
Mainstay = preventive therapy
1st line = Oxygen + Prednisone PO + Verapamil (preventer) PO
